Preferred term. People refer to themselves by tribal name (e.g., Sioux, Lakota, Navajo, Cherokee). When referring to tribes, older adults strongly prefer "American Indians" to "Native Americans." There are more than 500 federally recognized tribes, nations, bands, and native villages and an additional 200 native societies which do not benefit from federal recognition.
Major language and dialects. Most speak English. American Indians often use anecdotes or metaphors to discuss a situation. Telling about a neighbor who became ill may signal that patient feels similarly. Verbal discourse may be carefully constructed to provide precise meaning though examples, metaphors, etc; do not interrupt speaker. Long pauses are part of conversation. One hundred fifty indigenous languages continue to be spoken; however, do not ask, "Do you have an Indian name?" or "Will you say something in Indian?"
Greetings. Light tough handshake. Do not refer to men as chiefs or women as squaws.
one of Voice. Tone expresses urgency; when imperative command required, be direct, emphatic, clear, and calm. In making request, explain why it is needed. Loudness associated with aggression. Requests made in personable and polite manner are appreciated. Humor, self - humor, or willingness to be teased establishes comfortable and positive atmosphere.
Consents. To obtain consent, have conversation with patient explaining procedure and everyone's role, including role of patient (or family). In asking for signed consent, ask if patient is aware that procedure might be needed to achieve better understanding of health problem. Ask if patient needs to consult anyone before consenting; indicate that would be OK. Some individuals may be unwilling to sign written consent based on political and personal history of documents being misuse. Many clinicians note they have not been successful in having advance directives signed, but have achieved an understanding with American Indian clients of preference of natural processes. Overly structured consent processes may give American Indian families impression that they are not being heard, or provider believes they are not competent.
Privacy. Value placed on personal autonomy makes it unlikely that problems of family or friends will be freely discussed. However, illness may be seen as family matter, and immediate extended family may expect to be told condition of patient, test results, prognosis, etc. Names of deceased may be avoided, but relationship term (e.g., sister) can be used.
Serious or terminal illness. Who, how, what, when to discuss prognosis varies with tribe. Some cultures prefer not to openly discuss terminal status and DNR (Do Not Resuscitate) codes because negative thoughts might hasten inevitable loss. Other cultures use information to make appropriate preparation. Clinicians may wish to suggest family meeting to discuss condition and course of treatment.
Activities of Daily Living
Modesty. American Indians modest but not prudish. Offer women gown and robe, and offer men trousers and robe.
Skin care. Varies with individual, so ask.
Hair care. Hair cutting may be associated with health or mourning of a loved one. If procedures require cutting/shaving hair, give extra care to family concerns, and ask if hair needs to be returned to patient or family. If traditional hair style is worn, ask how to care for hair and who will arrange hair; allow access to family members who will provide this care. Other customs vary by tribe and include collection of hair from brush, avoidance of touching hair while pregnant, and ritual washing. Family may wish to ceremonially wash hair of very ill patient.
Nail care. Customs vary. Navajo may take care to collect nail parings.
Toileting. If there are unusual fixtures in hospital bathroom, explain their purpose. Modesty inconsistent with use of bedpan.
Special clothing or amulets. If medicine bag worn, every effort should be made not to remove it. If removal required, allow patient or family to handle, keep it close to the person, in view, and replace as soon as possible. DO NOT casually move, examine, or admire medicine bag.
Self - care. Be sure to tell patient (and/or family) of hospital amenities including library, magazine rack, radio or TV, cafeteria, vending machines, meal schedule, and hot to get extra food or fluids if needed. Self-care and self-healing with informal assistance expected at home. Often family may also provide care in hospital.
Usual diet. Traditional diets were low in fat with seasonal variability, but high fat diets predominate today and the current Pima diet estimated to be 35-50% fatty foods. Government supplied food commodities and Women Infant Children (WIC) programs provide many rural reservation and urban Indian families with following staples: sweetened condensed milk, cereal, flour, sugar, cooking oil, dry milk, canned vegetables, and processed cheeses. Indian fried bread, mutton stew, and other rich soups and stews are also common foods.
Pain. Pain generally under-treated in this population. American Indians may complain of pain in general terms such as, "I don't feel so good," or "something doesn't feel right." If patient reports being "uncomfortable" and gets no pain relief, patient unlikely to repeat request for assistance. Patient may complain of pain to trusted family member or visitor who will relay message to health care worker.
Dyspnea. Calmly offer reassurance and inquire as to character of dyspnea. Listen for such subtleties of expression as "The air is heavy; the air's not right" which may be complaints of dyspnea.
Nausea/vomiting. Vomiting may be source of embarrassment.
Constipation/diarrhea. When describing symptoms or accepting treatment, patient is matter-of-fact but modest.
Fatigue. May reflect psychosocial issues as well as physical problems. In general, a high level of activity is maintained in spite of a high level of poor health or functional impairment.
Depression. Depression generally recognized and despite concerns regarding cultural validity, standard screening tests for depression useful. Reporting of depression may be expressed as cultural metaphor such as having "heart problems," "being out of harmony," or having problems with social or physical universe. Often psychological problems presented as vague physical complaints.
Self-care. Traditional medicine may be used first or in combination with Western biomedicine. Preference for Western medicine varies with disease (e.g., diabetes generally recognized as introduced disease with no indigenous ritual or indigenous pharmacopeia), and individual lifestyle (e.g., traditional or "assimilated"). Self-care and self-healing integral to traditional wellness-oriented health concepts. Hygiene will be performed by patient if at all possible. Those cultures having extended family members in the same household may benefit from assistance of other family members. However, individuals may be isolated and without informal help in urban areas.
Preparation. Clinician may want to suggest family meeting to discuss end-of-life issues. Most American Indian cultures embrace the present. Some tribes avoid contact with the dying. If family want to be present 24 hours a day, this will include immediate and extended family and close friends. If family feels comfortable and welcome, atmosphere may be jovial with eating, joking, playing games, and singing. Small children also included. Although outcome tacitly recognized, positive attitude maintained, and family may avoid discussing impending death. Strong Hopi cultural value is to maintain positive attitude. Sadness and mourning done in private, away from patient. Patients encouraged and not demoralized by strong negative thoughts. Some may prefer to have an open window, or orient patient's body toward a cardinal direction prior to death. Once person is deceased, family may hug, touch, sing, stay close to the deceased. Wailing, shrieking, and other outward signs of grieving may occur, a starting contrast in demeanor.
Care of body. Care varies with culture and/or Christian beliefs. Traditional practices include turning and/or flexing body, sweetgrass smoke, or other purification; family (women) may want to prepare and dress the body. Family may choose to stay in room with deceased for a time and then have individual visitation. Health care professional should ask if acceptable to prepare the body in the room before individual visits begin. Some family will take the body home the night before burial to be cleansed and dressed, "spend the last night on earth," and for visitation by family and friends. Some families may wish the body to rest at place of death for up to 36 hours when soul is believed to depart. Laguna, for instance, do not permit the body to be prepared by mortuary, and family wraps body for burial. Other cultures avoid contact with the deceased and the deceased's possessions. Family may wish to have all of deceased's possessions including collected hair or nail parings.
Attitudes toward organ donation. If provider initiates frank and open discussion, be sure to distinguish fact from probability, to invite consultation with family members or others, and to indicate that consent or refusal are equally welcome. Organ donation generally not desired.
Attitudes toward autopsy. Generally autopsy not desired.
Composition/structure. Cultures vary in kinship structure. Examples are matrilineal clans in which related women form extended family core, patrilineages with direct descent reckoned through father-grandfather, etc. American Indians may try to explain relationship as "my brother Indian way" meaning cousin who has some role relationship to me as sibling. In some cultures, homosexually accepted as is adoption of cross-gender role activities; other cultures do not tolerate homosexually or cross-dressing except in ritualized contexts.
Decision making. Varies with kinship structure. Autonomy may be highly valued, and should not be assumed that spouse would presume an important decision for his/her partner. Children not expected to impose own wishes on parent's end-of-life decision.
Primary religious/spiritual affiliation. Depends on individual, may be traditional and/or Christian denominations. Do not expect American Indian patients to openly discuss traditional religion. In this last century, Congress passed legislation to ban traditional religion which remained in effect until 1979 Indian Freedom of Religion Act. Despite this law, traditional practice continues to be prosecuted in federal court jurisdictions when prayer objects are eagle feather or the sacrament is peyote.
Usual religious/spiritual practices. Depends on individual and varies with tribe.
Use of spiritual healing/healers. Depends on individual. May be combined with Western medicine to promote integration of healing mind and body. Discuss with healer how staff can be helpful, this may include having no staff present and no interruptions of ritual. If ritual objects, such as feathers, prayer staff, etc., present, do not casually admire, examine, or move these sacred items. If necessary, ask permission for them to be moved.
Source: Lipson, Juliene G., Dibble, Suzanne L., Minarik, Pamela A. Culture & Nursing Care: A Pocket Guide. The Regents. 1996